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Modern skin care services are noninvasive, have little downtime and allow for skin care professionals to combine multiple treatment modalities. The key to success for practicing estheticians is the tools and products they use, and their level of training with a commitment to continuing education. This includes having a thorough understanding of how each treatment modality operates individually and in combination with other treatments, and how they are applied to different skin types and conditions. Exfoliation represents one of these treatments.

In the context of skin care, exfoliation is simply the application of a technique or combination of methods to remove dead cells from the upper tissue layer of skin, the epidermis. It accelerates the natural process of desquamation—the shedding of the outer layer of skin— specifically the stratum corneum.

To understand exfoliation treatments and learn how to select the most suitable treatment systems for a client, you must first appreciate the basics of natural skin growth and desquamation. All exfoliation systems intercede in the skin’s natural processes by either kick-starting or accelerating them. At the same time, a fine balance must be achieved between stimulating skin rejuvenation and damaging the skin.

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Removal of the upper layers of the epidermis can take place via physiomechanical means, including abrasion, which detaches the loosely bound cells by shearing the cells apart; energy methods that break down the loose chemical bonds holding the cell matrix together; application of mild acids or enzymes to the skin to break down these chemical bonds; or uniquely targeted chemical agents that indirectly stimulate the desquamation process. As illustrated in Figure 1, each of the following methods differs in the skin depth that can be achieved.

Physical exfoliation

Scrubs are products with abrasive ingredients that physically remove the top layer of the epidermis. Ingredients utilized in scrubs include ground-up natural seeds, such as walnuts and grains, as well as mineral granules, such as salt. Man-made exfoliating ingredients include fine synthetic polymer beads. (See Microbeads Under Fire to learn more about how and why states are starting to ban man-made microbeads in products.) Gommages also fall into this category, because the product is applied and then manually rubbed off, along with any skin that is loosened in the process. Physical scrub ingredients that are more malleable offer a safer approach, because they are less abrasive to the skin. Gentle physical exfoliants should be the only physical exfoliants used for sensitive, acne-prone, rosacea-prone or mature, thinned skin.

Chemical exfoliation

Chemical exfoliants rely on the power of the ingredient to soften, lift and delaminate the skin. There are many different types of acid peels and enzymes that fall into this category.

Acid peels. Acid peels work due to their acidity, which is measured by pH, defining the acid’s willingness to donate an H+ ion. The more H+ ions in the peel, the lower the pH of the liquid, and the more the peel is able to break the weak bonds that link skin cells, translating to more peeling. The beauty of acid peel systems is that a skin care professional can customize results by matching the correct peel to the proper skin type in order to maximize results and minimize downtime. Refer to my “Peel Science” article in the February 2014 issue of Skin Inc. magazine for more details on all the different types of peels, and how to select the best peel for each skin type and concern.

Enzyme products. Enzymes utilized in skin care primarily include those that digest protein in skin, such as keratin, which is present in high concentrations in the upper layer of the epidermis. Papain from papaya and bromelain from pineapple are two of the most common enzymes. Enzymes are generally very safe, because they have a limited reactivity with skin due to the fact that they can only digest the keratin protein they come into direct contact with. The key to success with enzyme systems is keeping the enzyme active before it is applied to the skin. For instance, a single-enzyme product that contains water and enzyme has a very short shelf life, because the enzyme can digest itself. Also, it should be noted that many enzyme products are formulated together with acids, which can make the exfoliation more aggressive. These treatments should be categorized as chemical acid peels rather than an enzyme. Very often, these additives are not disclosed; therefore, skin care professionals should be sure to test different enzyme products and choose the appropriate strength for a specific client.

Mechanical exfoliation

Mechanical brushes. An oscillating brush uses sonic technology to move back and forth, creating a shearing action on the skin. The oscillating frequency can be varied to achieve different results. Alternatively, rotating brushes continuously spin in one direction. The key to both systems is the brush itself. It is important to use soft brushes that limit abrasion to the skin, and to change them frequently to replace worn or frayed brush fibers, and to maintain a microbe-free environment. This method is recommended for all skin types; however, minimal and careful usage is recommended for sensitive, acne, rosacea or thin, mature skin.

Microdermabrasion. Traditional microdermabrasion consists of simultaneously applying a high-velocity stream of small crystals to the skin, such as aluminum oxide, through a small, hand-held device in order to “chip away” at the surface cells while continuously applying suction to remove the freed cells, dirt and crystals. Besides aluminum oxide, other materials used include corundum, found in rubies and sapphires. As a more benign alternative, sodium bicarbonate (baking soda) has also been used, producing less aggressive results due to its softer nature. Machines that use salt are also available; however, the salt crystals tend to be coarser than traditional minerals and, therefore, produce more of a macrodermabrasion effect.

Abrasive-wand microdermabrasion. Machines featuring a wand with a small, abrasive disc head are also utilized. One type uses a diamond dermabrasion disc, replacing the microcrystal flow, which can cause a fine sheen on the face. Areas closer to the eyes and mouth can be abraded more delicately with diamond abrasion, because there is no risk of stray crystals causing damage or being ingested. Different companies offer either disposable or reusable tips that vary in size and coarseness, allowing skin care professionals to manipulate the amount of exfoliation.

Aqueous vortex dermabrasion. These machines use high-velocity water jets to produce a circular flow on the skin in order to pull out impurities, along with any dead skin cells. Using a unique, patented handpiece, a circular flow is created on the skin as the tool is applied. This is often combined with the application of various serums and products to enhance results.

Dermaplaning. In this method, a scalpel blade is used to debride the top layer of skin and remove fine baby hairs on the face. It has the effect of making the skin very soft immediately after the procedure. This treatment is similar to a man’s daily shaving routine, which removes old skin, as well as beard hair. A negative potential side effect is that the hair regrowth may be coarser and darker.

Energy exfoliation

Laser skin resurfacing uses light waves to stimulate the skin’s natural healing process and increase collagen production in the skin.

There are many different types of lasers that can impact the skin in different ways. Some remove all or part of the epidermal layers—this process is known as laser ablation, and it stimulates the body’s natural healing process to eliminate lines, wrinkles, acne scars, brown spots, age spots, sun damage, sun spots and other visible imperfections on the outer skin. Other lasers can reach into the lower layer of the skin, the dermis, to stimulate collagen production, giving skin more elasticity. Some lasers combine both effects.

Carbon dioxide (CO2) lasers.These have been used in ablative skin resurfacing longer than any other type of laser. They are considered aggressive treatments and have the longest recovery time.

Erbium lasers. These affect less of the surrounding tissue than CO2 lasers. Therefore, downtime may be less and recovery may be quicker, with fewer side effects. This may be more appropriate for darker-skinned clients than CO2 lasers.

Fractional lasers. Using thousands of tiny beams of light to treat a pre-determined percentage of the skin, this fractional treatment allows the skin to heal much faster than if the entire surface of the skin was treated at once. These lasers may be either CO2 or erbium.

Combine and conquer

Today, skin care professionals have multiple tools at their disposal to exfoliate the skin. With these tools, services can be customized to:

Achieve the desired depth of the exfoliation;

The client’s tolerance;

The number of follow-up procedures that may be necessary; and

The amount of downtime.

As Figure 2 depicts, today’s exfoliation systems range from milder methods, such as physical abrasion, to more aggressive methods, such as lasers. For advanced treatments, one or more systems can be combined, but they should never be performed without being applied individually first. All techniques described affect a wounding process that induces a healing process, resulting in new, fresher skin. The healing phase is as critical a component of the treatment as the exfoliation wounding process. Because of this, an equal amount of attention and care must be placed on the treatment, both during the service and in the weeks that follow. Post-exfoliation home care should include a regimen that addresses sensitive, inflamed, dehydrated and peeling skin with reduced inherent barrier function. Modern exfoliation is most effective when it combines multiple exfoliation and repair modalities, giving the client healthy, balanced and long-term results.

President and founder of Ecozone, Inc. and Dermaware Bio-Targeted Skin Care, Gül Ç. Zone has combined her biomedical formulary background and cosmetic marketing expertise to develop Dermaware corrective skin care for esthetic spa and medical practitioners. Her knowledge has also contributed to the development of several international skin care lines.